Showing papers in "Journal of Clinical Hypertension in 2008"
TL;DR: The medication adherence measure proved to be reliable, with good concurrent and predictive validity in primarily low‐income, minority patients with hypertension and might function as a screening tool in outpatient settings with other patient groups.
Abstract: This study examines the psychometric properties and tests the concurrent and predictive validity of a structured, self-reported medication adherence measure in patients with hypertension We also assessed various psychosocial determinants of adherence, such as knowledge, social support, satisfaction with care and complexity of the medical regimen A total of 1367 patients participated in the study; mean age was 525 years, 408% were male, 765% were black, 51% graduated from high school, 26% were married, and 541% had income <$5,000 The eight-item medication adherence scale was reliable (α= 083) and significantly associated with blood pressure control (P<005) Using a cutpoint of less than 6, the sensitivity of the measure for identifying low versus higher adherers was estimated to be 93%, and the specificity was 53% The medication adherence measure proved to be reliable with good concurrent and predictive validity in primarily low income, minority patients with hypertension, and might function as a screening tool in outpatient settings with other patient groups
2,456 citations
TL;DR: NO has also been implicated in the pathology of many inflammatory diseases, including arthritis, myocarditis, colitis, and nephritis and a large number of pathologic conditions such as amyotrophic lateral sclerosis, cancer, diabetes, and neurodegenerative diseases.
Abstract: In contrast with the short research history of the enzymatic synthesis of nitric oxide (NO), the introduction of nitrate-containing compounds for medicinal purposes marked its 150th anniversary in 1997. Glyceryl trinitrate (nitroglycerin) is the first compound of this category. On October 12, 1998, the Nobel Assembly awarded the Nobel Prize in Medicine or Physiology to scientists Robert Furchgott, Louis Ignarro, and Ferid Murad for their discoveries concerning NO as a signaling molecule in the cardiovascular system. NO-mediated signaling is a recognized component in various physiologic processes (eg, smooth muscle relaxation, inhibition of platelet and leukocyte aggregation, attenuation of vascular smooth muscle cell proliferation, neurotransmission, and immune defense), to name only a few. NO has also been implicated in the pathology of many inflammatory diseases, including arthritis, myocarditis, colitis, and nephritis and a large number of pathologic conditions such as amyotrophic lateral sclerosis, cancer, diabetes, and neurodegenerative diseases. Some of these processes (eg, smooth muscle relaxation, platelet aggregation, and neurotransmission) require only a brief production of NO at low nanomolar concentrations and are dependent on the recruitment of cyclic guanosine monophosphate (cGMP)-dependent signaling. Other processes are associated with direct interaction of NO or reactive nitrogen species derived from it with target proteins and requires a more sustained production of NO at higher concentrations but do not involve the cGMP pathway.
210 citations
TL;DR: The roles of potassium, magnesium, and calcium in the prevention and treatment of essential hypertension with specific emphasis on clinical trial evidence, mechanism of action, and recommendations for dietary intake of these minerals are discussed.
Abstract: Despite advances in the prevention and treatment of hypertension over the past decade, hypertension remains an important public health challenge. Recent efforts to reduce the prevalence of hypertension have focused on nonpharmacologic means, specifically diet. An increased intake of minerals such as potassium, magnesium, and calcium by dietary means has been shown in some but not all studies to reduce blood pressure in patients with hypertension. This review will discuss the roles of potassium, magnesium, and calcium in the prevention and treatment of essential hypertension with specific emphasis on clinical trial evidence, mechanism of action, and recommendations for dietary intake of these minerals. A high intake of these minerals through increased consumption of fruits and vegetables may improve blood pressure levels and reduce coronary heart disease and stroke.
202 citations
TL;DR: Physician/pharmacist collaboration achieved significantly better mean BP values and overall BP control rates, primarily by intensification of medication therapy and improving patient adherence.
Abstract: This was a prospective, cluster randomized controlled trial in patients with uncontrolled hypertension aged 21 to 85 years (mean, 61 years). Pharmacists made recommendations to physicians for patients in the intervention clinics (n=101) but not patients in the control clinics (n=78). The mean adjusted difference in systolic blood pressure (BP) between the control and intervention groups was 8.7 mm Hg (95% confidence interval [CI], 4.4-12.9), while the difference in diastolic BP was 5.4 mm Hg (CI, 2.8-8.0) at 9 months. The 24-hour BP levels showed similar effects, with a mean systolic BP level that was 8.8 mm Hg lower (CI, 5.0-12.6) and a mean diastolic BP level that was 4.6 mm Hg (CI, 2.4-6.8) lower in the intervention group. BP was controlled in 89.1% of patients in the intervention group and 52.9% in the control group (adjusted odds ratio, 8.9; CI, 3.8-20.7; P<.001). Physician/pharmacist collaboration achieved significantly better mean BP values and overall BP control rates, primarily by intensification of medication therapy and improving patient adherence.
201 citations
TL;DR: Brachial systolic and pulse blood pressures are better predictors of adverse cardiovascular events than diastolic BP in individuals older than 50 years and central BP, the pressure exerted on the heart, brain, and kidneys, is a better predictor of CV risk than brachial BP.
Abstract: Brachial systolic and pulse blood pressures (BPs) are better predictors of adverse cardiovascular (CV) events than diastolic BP in individuals older than 50 years The principal cause of increased systolic and pulse BP is increased stiffness of the elastic arteries as a result of degeneration and hyperplasia of the arterial wall Recent studies have shown that central BP, the pressure exerted on the heart, brain, and kidneys, is a better predictor of CV risk than brachial BP As stiffness increases, reflected wave amplitude increases and augments pressure in late systole, producing an increase in left ventricular afterload and myocardial oxygen demand Vasoactive drugs have little direct effect on large human elastic arteries but can markedly modify wave reflection by altering stiffness of the muscular arteries and changing pulse wave velocity of the reflected wave from the periphery to the heart Vasodilators decrease the amplitude and increase the travel time (or delay) of the reflected wave, causing a generalized decrease in systolic BP The decrease in systolic BP brought about by this mechanism is grossly underestimated when systolic BP is measured in the brachial artery
181 citations
TL;DR: In this paper, the authors made the following recommendations: (1) it is recommended that HBPM should become a routine component of BP measurement in the majority of patients with known or suspected hypertension; (2) patients should be advised to purchase oscillometric monitors that measure BP on the upper arm with an appropriate cuff size and that have been shown to be accurate according to standard international protocols.
Abstract: Home blood pressure monitoring (HBPM) overcomes many of the limitations of traditional office blood pressure (BP) measurement and is both cheaper and easier to perform than ambulatory BP monitoring. Monitors that use the oscillometric method are currently available that are accurate, reliable, easy to use, and relatively inexpensive. An increasing number of patients are using them regularly to check their BP at home, but although this has been endorsed by national and international guidelines, detailed recommendations for their use have been lacking. There is a rapidly growing literature showing that measurements taken by patients at home are often lower than readings taken in the office and closer to the average BP recorded by 24-hour ambulatory monitors, which is the BP that best predicts cardiovascular risk. Because of the larger numbers of readings that can be taken by HBPM than in the office and the elimination of the white-coat effect (the increase of BP during an office visit), home readings are more reproducible than office readings and show better correlations with measures of target organ damage. In addition, prospective studies that have used multiple home readings to express the true BP have found that home BP predicts risk better than office BP (class IIa; level of evidence A). This call-to-action article makes the following recommendations: (1) It is recommended that HBPM should become a routine component of BP measurement in the majority of patients with known or suspected hypertension; (2) Patients should be advised to purchase oscillometric monitors that measure BP on the upper arm with an appropriate cuff size and that have been shown to be accurate according to standard international protocols. They should be shown how to use them by their healthcare providers; (3) Two to 3 readings should be taken while the subject is resting in the seated position, both in the morning and at night, over a period of 1 week. A total of > or =12 readings are recommended for making clinical decisions; (4) HBPM is indicated in patients with newly diagnosed or suspected hypertension, in whom it may distinguish between white-coat and sustained hypertension. If the results are equivocal, ambulatory BP monitoring may help to establish the diagnosis; (5) In patients with prehypertension, HBPM may be useful for detecting masked hypertension; (6) HBPM is recommended for evaluating the response to any type of antihypertensive treatment and may improve adherence; (7) The target HBPM goal for treatment is <135/85 mm Hg or <130/80 mm Hg in high-risk patients; (8) HBPM is useful in the elderly, in whom both BP variability and the white-coat effect are increased; (9) HBPM is of value in patients with diabetes, in whom tight BP control is of paramount importance; (10) Other populations in whom HBPM may be beneficial include pregnant women, children, and patients with kidney disease; and (11) HBPM has the potential to improve the quality of care while reducing costs and should be reimbursed.
161 citations
TL;DR: There is an obvious gap in the translation of clinical trial evidence into practice with regards to optimal hypertension control because of the failure of health care providers to initiate or intensify drug therapy in a patient with uncontrolled BP.
Abstract: There is an obvious gap in the translation of clinical trial evidence into practice with regards to optimal hypertension control. The three major categories of barriers to BP control are patient-related, physician-related, and medical environment/health care system factors. Patient-related barriers include poor medication adherence, beliefs about hypertension and its treatment, depression, health literacy, comorbidity, and patient motivation. The most pertinent is medication adherence, given its centrality to the other factors. The most salient physician-related barrier is clinical inertia--defined, as the failure of health care providers to initiate or intensify drug therapy in a patient with uncontrolled BP. The major reasons for clinical inertia are: 1) overestimation of the amount of care that physicians provide; 2) lack of training on how to attain target BP levels; and 3) clinicians' use of soft reasons to avoid treatment intensification by adopting a "wait until next visit" approach in response to patients' excuses.
137 citations
TL;DR: This review analyzes the status of hypertension control in the United States, the frequency of associated diseases, and adherence to guidelines; it further discusses strategies to reduce the prevalence of resistant hypertension.
Abstract: An improvement in the awareness and treatment of hypertension in the United States has occurred, resulting in the best control rates in the world, which unfortunately are far below the goals of Healthy People 2000 or 2010. This failure to achieve blood pressure (BP) goals is attributed to many factors, including an aging population, higher prevalence of kidney disease and obesity, high salt intake, physician inertia to increase dose and number of antihypertensive medications prescribed, and patient nonadherence with medication regimens. Resistant hypertension is defined as a failure to achieve goal BP in patients who adhere to full doses of an appropriate antihypertensive regimen of 3 drugs that includes a diuretic. The problem of resistant hypertension is projected to increase as the population ages. Efforts on the part of the Veterans Administration hospitals and others clearly indicate that a system can be implemented to help increase the percentage of persons in whom BP goal is achieved and reduce the prevalence of resistant hypertension. Medications specific to the problem of resistant hypertension are also under development. This review analyzes the status of hypertension control in the United States, the frequency of associated diseases, and adherence to guidelines; it further discusses strategies to reduce the prevalence of resistant hypertension.
118 citations
TL;DR: Support for the BP‐lowering benefits of complementary antihypertensive therapy with amlodipine and valsartan in patients with hypertension uncontrolled by previous monotherapy is provided.
Abstract: In this randomized, double-blind, multicenter study, patients whose blood pressure (BP) was uncontrolled by monotherapy were switched directly to amlodipine/valsartan 5/160 mg (n=443) or 10/160 mg (n=451). After 16 weeks, BP control (levels <140/90 mm Hg or <130/80 mm Hg for diabetics) was achieved in 72.7% (95% confidence interval [CI], 68.6-76.9) of patients receiving amlodipine/valsartan 5/160 mg and in 74.8% (95% CI, 70.8-78.9) receiving amlodipine/valsartan 10/160 mg. Incremental reductions from baseline in mean sitting systolic and diastolic BP were significantly greater with the higher dose (20.0+/-0.7 vs 17.5+/-0.7 mm Hg; P=.0003 and 11.6+/-0.4 vs 10.4+/-0.4 mm Hg; P=.0046). Incremental BP reductions were also achieved with both regimens irrespective of previous monotherapy, hypertension severity, diabetic status, body mass index, and age. Peripheral edema was the most frequent adverse event. These results provide support for the BP-lowering benefits of complementary antihypertensive therapy with amlodipine and valsartan in patients with hypertension uncontrolled by previous monotherapy.
113 citations
TL;DR: Single‐pill, or fixed‐dose, combination therapy is one approach that improves adherence, while also providing the antihypertensive efficacy needed to help patients achieve their blood pressure goals.
Abstract: Inadequate control of blood pressure may be attributed to both provider-related and patient-related factors. Health care provider-related factors may include an excessive reliance on monotherapy and reluctance to increase drug doses or add additional antihypertensive agents to the treatment regimen. The primary patient-related factor is nonadherence with the prescribed antihypertensive medication. Although the high cost of therapy is sometimes a reason for poor adherence, drug side effects or dosing considerations may be more important factors. Better adherence with antihypertensive medication is associated with a significantly greater likelihood of achieving blood pressure control and, consequently, with lower costs and reduced utilization of health care resources. Therefore, strategies that improve long-term adherence should be adopted. Single-pill, or fixed-dose, combination therapy is one approach that improves adherence, while also providing the antihypertensive efficacy needed to help patients achieve their blood pressure goals.
112 citations
Veterans Health Administration1, University of Texas Health Science Center at Houston2, National Institutes of Health3, Case Western Reserve University4, Medical University of South Carolina5, Loyola University Chicago6, Bristol-Myers Squibb7, Tulane University8, Howard University9, Cleveland Clinic10
TL;DR: Over time, providers and patients should expect multidrug therapy to achieve BP <140/90 mm Hg in a majority of patients.
Abstract: Blood pressure (BP) control rates and number of antihypertensive medications were compared (average follow-up, 4.9 years) by randomized groups: chlorthalidone, 12.5–25 mg/d (n=15,255), amlodipine 2.5–10 mg/d (n=9048), or lisinopril 10–40 mg/d (n=9054) in a randomized double-blind hypertension trial. Participants were hypertensives aged 55 or older with additional cardiovascular risk factor(s), recruited from 623 centers. Additional agents from other classes were added as needed to achieve BP control. BP was reduced from 145/83 mm Hg (27% control) to 134/76 mm Hg (chlorthalidone, 68% control), 135/75 mm Hg (amlodipine, 66% control), and 136/76 mm Hg (lisinopril, 61% control) by 5 years; the mean number of drugs prescribed was 1.9, 2.0, and 2.1, respectively. Only 28% (chlorthalidone), 24% (amlodipine), and 24% (lisinopril) were controlled on monotherapy. BP control was achieved in the majority of each randomized group—a greater proportion with chlorthalidone. Over time, providers and patients should expect multidrug therapy to achieve BP <140/90 mm Hg in a majority of patients.
TL;DR: Neither ABPM nor self-BP monitoring are mandatory for the routine diagnosis of hypertension, but these modalities can enhance the ability for identification of white-coat and masked hypertension and evaluate the extent of BP control in patients on drug therapy.
Abstract: This American Society of Hypertension position paper focuses on the importance of out-of-office blood pressure (BP) measurement for the clinical management of patients with hypertension and its complications. Studies have supported direct and independent associations of cardiovascular risk with ambulatory BP and inverse associations with the degree of BP reduction from day to night. Self-monitoring of the BP (or home BP monitoring) also has advantages in evaluating patients with hypertension, especially those already on drug treatment, but less is known about its relation to future cardiovascular events. Data derived from ambulatory BP monitoring (ABPM) allow the identification of high-risk patients, independent from the BP obtained in the clinic or office setting. While neither ABPM nor self-BP monitoring are mandatory for the routine diagnosis of hypertension, these modalities can enhance the ability for identification of white-coat and masked hypertension and evaluate the extent of BP control in patients on drug therapy. © 2008 American Society of Hypertension. All rights reserved.
TL;DR: In a multivariate model, younger age, lower income, having mental function impairment, and having had a blood pressure check more than 6 months earlier were factors significantly associated with reporting difficulty taking prescribed antihypertensive drugs.
Abstract: Antihypertensive agents are one of the most commonly prescribed classes of medications in the country, but patient adherence rates are low. To better understand why rates are low, the authors used data from the 2005 HealthStyles survey and found that among the 1432 respondents who received prescriptions for antihypertensive medications, 407 (28.4%) reported having difficulty taking their medication. ``Not remembering'' was the most common reason reported (32.4%), followed by cost (22.6%), having no insurance (22.4%), side effects (12.5%), other reasons (12.3%), not thinking there is any need (9.3%), and having no health care provider (4.7%). In a multivariate model, younger age, lower income, having mental function impairment, and having had a blood pressure check more than 6 months earlier were factors significantly associated with reporting difficulty taking prescribed antihypertensive drugs. Control of hypertension is a significant public health issue, and alleviating barriers to medication adherence should be a major goal toward hypertension management.
Boston Children's Hospital1, AstraZeneca2, University of Pennsylvania3, Ghent University4, University of Virginia5, University of Michigan6, Thomas Jefferson University7, Yeshiva University8, Eastern Virginia Medical School9, University of Utah10, University of Miami11, Rush University Medical Center12, Wake Forest University13, University of Louisville14, University of Texas Health Science Center at Houston15, Oregon Health & Science University16, University of Pittsburgh17, Maimonides Medical Center18, University of Mississippi19, Georgia Regents University20, Medical University of South Carolina21
TL;DR: C candesartan is an effective, well‐tolerated antihypertensive agent for children aged 6 to 17 years and has a pharmacokinetic profile that is similar to that in adults.
Abstract: This 4-week randomized, double blind, placebo-controlled study (N=240), 1-year open label trial (N=233), and single-dose pharmacokinetic study (N=22) evaluated candesartan cilexetil (3 doses) in hypertensive children aged 6 to 17 years. Seventy-one percent were 12 years of age or older, 71% were male, and 47% were black. Systolic (SBP)/diastolic (DBP) blood pressure declined 8.6/4.8-11.2/8.0 mm Hg with candesartan and 3.7/1.8 mm Hg with placebo (P .05). The response rate (SBP and DBP <95th percentile) after 1 year was 53%. The pharmacokinetic profiles in 6- to 12- and 12- to 17-year-olds were similar and were comparable to adults. Eight candesartan patients discontinued treatment because of an adverse event. Candesartan is an effective, well-tolerated antihypertensive agent for children aged 6 to 17 years and has a pharmacokinetic profile that is similar to that in adults.
TL;DR: This treatment strategy, based on standardized rest as an initial step and different antihypertensive drugs, can be effective and safe for the management of patients with hypertensive urgencies.
Abstract: To study the efficacy of a treatment strategy for the management of hypertensive urgencies, the authors evaluated 549 patients admitted to the emergency department. They were first assigned to a 30-minute rest period, then a follow-up blood pressure measurement was carried out. Patients who did not respond to rest were randomly assigned to receive an oral dose of an antihypertensive drug with different mechanisms of action and pharmacodynamic properties (perindopril, amlodipine, or labetalol), and blood pressure was reassessed at 60- and 120-minute intervals. A satisfactory blood pressure response to rest (defined as postintervention systolic blood pressure < 180 mm Hg and diastolic blood pressure < 110 mm Hg, with at least a 20 mm Hg reduction in basal systolic blood pressure and/or a 10-mm Hg reduction in basal diastolic blood pressure) was observed in 31.9% of population. Among nonresponders, 79.1% had a satisfactory blood pressure response to the antihypertensive drug treatment in a 2-hour average follow-up period. No major adverse events were observed. This treatment strategy, based on standardized rest as an initial step and different antihypertensive drugs, can be effective and safe for the management of patients with hypertensive urgencies.
TL;DR: Nocturnal BP rise on ambulatory monitoring is superior to office BP to predict worsening of albuminuria in elderly individuals with type 2 diabetes and adds to the information provided by 24‐hour pulse pressure.
Abstract: Ambulatory 24-hour pulse pressure predicts progression of albuminuria in persons with diabetes mellitus. The authors assessed whether nocturnal blood pressure (BP) patterns added predictive information and examined the multivariate-adjusted association of nocturnal BP patterns with progression of urine albumin excretion during follow-up in a multiethnic cohort of older people (n=957) with type 2 diabetes mellitus who were free of macroalbuminuria. Albuminuria was assessed by spot urine measurement of albumin-to-creatinine ratio at baseline and annually for 3 years. Participants were categorized according to their sleep/wake systolic BP ratio as dippers (ratio 0.9 to 1; n=475), and nocturnal BP risers (ratio >1; n=187). The proportion exhibiting progression of albuminuria in dippers, nondippers, and risers was 17.6%, 22.9%, and 27.3%, respectively (P for linear trend = .01). A nocturnal BP rise was independently associated with progression of albuminuria (hazard ratio, 1.68; 95% confidence interval [CI], 1.09-2.60; P=.02), whereas office pulse pressure was not. When ambulatory 24-hour pulse pressure was added to the model, the nocturnal BP rise remained an independent predictor of progression of albuminuria (hazard ratio, 1.58; 95% CI, 1.02-2.45; P=.04). Nocturnal nondipping (without BP increase) was not an independent predictor. In conclusion, nocturnal BP rise on ambulatory monitoring is superior to office BP to predict worsening of albuminuria in elderly individuals with type 2 diabetes and adds to the information provided by 24-hour pulse pressure.
TL;DR: Questions such as what to do when a patient has an elevated potassium level when therapy is initiated and whether combinations of agents that block the renin‐angiotensin system still be used are addressed.
Abstract: This report updates concepts on hypertension management in patients with diabetes. It focuses on clinical outcomes literature published within the last 3 years and incorporates these observations into modifications of established guidelines. While the fundamentals of treatment and goal blood pressures remain unchanged, approaches to specific patient-related issues has changed. This update focuses on questions such as what to do when a patient has an elevated potassium level when therapy is initiated and whether combinations of agents that block the renin-angiotensin system still be used. In addition, there are updates from trials, just published and in press, that focus on related management issues influencing cardiovascular outcomes in persons with diabetes. Last, an updated algorithm is provided that incorporates many of the new findings and is suggested as a starting point to achieve blood pressure goals.
TL;DR: Emphasis is placed on the chronic management of patients who have experienced mild hyponatremia, in whom decisions about treatment with diuretic and nondiuretic antihypertensive agents must be made to satisfy the twin goals of controlling hypertension and avoiding recurrent hypon atremia.
Abstract: Hyponatremia is a recognized complication of treatment with thiazide diuretics, particularly in patients older than 70 years. Severe and symptomatic hyponatremia requires urgent management, usually requiring infusion of normal or hypertonic saline. Milder, asymptomatic, thiazide-induced hyponatremia requires steps to manage the hyponatremia as well as to prevent its future recurrence. This is a particular problem in patients who despite a history of thiazide-induced hyponatremia might require a diuretic in the management of their hypertension. In this review, the acute management of symptomatic and asymptomatic thiazide-induced hyponatremia is reviewed. Emphasis is also placed on the chronic management of patients who have experienced mild hyponatremia, in whom decisions about treatment with diuretic and nondiuretic antihypertensive agents must be made to satisfy the twin goals of controlling hypertension and avoiding recurrent hyponatremia.
TL;DR: These include home‐based disease management, combined patient and provider education, and automatic decision support systems are reviewed and current and potential creative strategies for optimizing blood pressure control are described.
Abstract: Many quality improvement strategies have focused on improving blood pressure control, and these strategies can target the patient, the provider, and/or the system. Strategies that seem to have the biggest effect on blood pressure outcomes are team change, patient education, facilitated relay of clinical information, and promotion of self-management. Barriers to effective blood pressure control can affect the patient, the physician, the system, and/or "cues to action."We review the barriers to achieving blood pressure control and describe current and potential creative strategies for optimizing blood pressure control. These include home-based disease management, combined patient and provider education, and automatic decision support systems. Future research must address which components of quality improvement interventions are most successful in achieving blood pressure control.
TL;DR: The case highlights the importance of obtaining a detailed dietary history, especially considering the increasing use of liquorice‐containing foods, teas, and herbal products, and the authors discuss secondary causes of hypertension, focusing on pseudohyperaldosteronism.
Abstract: Consumption of large quantities of liquorice can cause hypokalemia and hypertension. These effects are associated with increased cortisol-mediated activation of renal mineralocorticoid receptors and hypoaldosteronism. The authors describe a patient with long-standing hypokalemia and uncontrolled hypertension related to excessive ingestion of liquorice. The case highlights the importance of obtaining a detailed dietary history, especially considering the increasing use of liquorice-containing foods, teas, and herbal products. The authors also discuss secondary causes of hypertension, focusing on pseudohyperaldosteronism.
TL;DR: Hyperaldosteronism is now recognized as the most common cause of resistant hypertension, and all patients with resistant hypertension should be screened with a plasma aldosterone/renin ratio even if the serum potassium level is normal.
Abstract: Resistant hypertension is defined as blood pressure (BP) that remains uncontrolled in spite of the use of ≥3 antihypertensive medications. Stricter BP goals, higher obesity rates, older age, and increased use of exogenous BP-elevating substances are related to an increasing prevalence of resistant hypertension. The evaluation of patients with resistant hypertension is focused on identifying contributing and secondary causes of hypertension, including hyperaldosteronism, obstructive sleep apnea, chronic kidney disease, renal artery stenosis, and pheochromocytoma. Hyperaldosteronism is now recognized as the most common cause of resistant hypertension, and all patients with resistant hypertension should be screened with a plasma aldosterone/renin ratio even if the serum potassium level is normal. Treatment includes removal of contributing factors, appropriate management of secondary causes, and use of effective multidrug regimens. Recent studies indicate that the addition of spironolactone to standard treatment induces significant BP reduction in most patients with resistant hypertension.
TL;DR: In this article, the authors examined whether the receipt of advice is associated with reported adoption of lifestyle modifications, such as changing eating habits, reducing salt intake, exercising, or decreasing alcohol consumption.
Abstract: Routine lifestyle modification advice for managing high blood pressure (BP) is of questionable effectiveness. Using data from the 2005 Behavior Risk Factor Surveillance System, we examined whether receipt of advice is associated with reported adoption of lifestyle modifications. We determined proportions of hypertensive adults taking action to change eating habits, reduce salt intake, exercise, or decrease alcohol consumption to control high BP. We then determined associations between reports of advice given and corresponding actions being taken: 70.1% of respondents reported changing eating habits, 78.7% reported reducing salt intake, 67.1% reported exercising, and 57.9% of those who drank alcohol reported decreasing their consumption. Compared with those who did not recall being given advice, hypertensive adults who recalled being given advice were more likely to change their eating habits (prevalence ratio [PR], 1.62; 95% confidence interval [CI], 1.56-1.67), reduce salt (PR, 1.53; 95% CI, 1.48-1.58), exercise (PR, 1.41; 95% CI, 1.36-1.47), and reduce alcohol consumption (PR, 1.78; 95% CI, 1.70-1.87).
TL;DR: Clinical trials demonstrate that both the dihydropyridine calcium channel blocker amlodipine and angiotensin II receptor blockers are effective agents for the management of hypertension in individuals with or without cardiovascular disease.
Abstract: Fixed-dosed combination regimens consisting of a calcium channel blocker and an angiotensin II type 1 receptor blocker represent a new addition to the available antihypertensive treatment options. Clinical trials demonstrate that both the dihydropyridine calcium channel blocker amlodipine and angiotensin II receptor blockers are effective agents for the management of hypertension in individuals with or without cardiovascular disease. When combined, these 2 classes of agents have complementary effects on blood pressure, as each targets separate signaling pathways in the vasculature pivotal to the regulation of vascular function. In clinical trials this combination has demonstrated better efficacy, defined by time to reach blood pressure targets as well as levels of blood pressure achieved, compared with the individual agents. In a comparative trial, a combination of amlodipine plus valsartan (an angiotensin II receptor blocker) also produced greater reductions in blood pressure compared with a combination of lisinopril (an angiotensin-converting enzyme inhibitor) and hydrochlorothiazide. The combination of amlodipine and an angiotensin II receptor blocker is well tolerated, including in patients with stage 2 hypertension and the elderly.
TL;DR: Careful evaluation of a patient's drug regimen may identify chemically induced hypertension and obviate unnecessary evaluation and direct to the optimal antihypertensive therapy.
Abstract: A variety of therapeutic agents or chemical substances can induce either a transient or persistent increase in blood pressure or interfere with the blood pressure-lowering effects of antihypertensive drugs. Some agents either cause sodium retention and extracellular volume expansion or directly or indirectly activate the sympathetic nervous system. Other substances act directly on arteriolar smooth muscle or do not have a defined mechanism of action. Some medications that usually lower blood pressure may paradoxically increase blood pressure, and an increase in pressure may be encountered after their discontinuation. In general, these pressure increases are small and transient; however, severe hypertension involving encephalopathy, stroke, and irreversible renal failure have been reported. Careful evaluation of a patient's drug regimen may identify chemically induced hypertension and obviate unnecessary evaluation and direct to the optimal antihypertensive therapy. The present review summarizes the therapeutic agents or chemical substances that elevate blood pressure and their mechanisms of action.
TL;DR: In areas where significant changes in day temperature and daylight duration exist at different times of the year, blood pressure, serum cholesterol, and HDL‐C levels change accordingly in a cycle with higher blood pressure and serum total cholesterol and lower HDL-C values in the coldest season.
Abstract: In this study, a group of controls and patients with essential hypertension were followed up for 1 year. Four measurements at different day temperatures were performed. In each visit, blood pressure, serum total cholesterol, and high-density lipoprotein cholesterol (HDL-C) were measured. The results showed a significant inverse relationship between mean blood pressure and serum total cholesterol levels with day temperature, while a direct relationship was observed for HDL-C value. These results suggest that in areas where significant changes in day temperature and daylight duration exist at different times of the year, blood pressure, serum cholesterol, and HDL-C levels change accordingly in a cycle with higher blood pressure and serum total cholesterol and lower HDL-C values in the coldest season.
TL;DR: This section focuses on the treatment of hypertension in special circumstances and special populations: pregnancy, preeclampsia, and lactation; hypertension in black women; and hypertension in the elderly.
Abstract: The basis for the treatment of hypertension in women has evolved in step with the inclusion of women in studies of treatment in hypertension. Recent outcome trials comparing angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or calcium antagonists with diuretics and beta-blockers in older, high-risk patients have generally shown similar benefits for women and men. The current evidence therefore indicates that sex should not play a role in decisions about whether to treat hypertension or about the choice of agents.
TL;DR: There were no differences between combination valsartan/HCTZ or monotherapies on a measure of insulin sensitivity and inflammatory/metabolic biomarkers in prediabetic hypertensive persons with CMS, indicating an ameliorating effect of valsArtan on these measures.
Abstract: Hypertensive patients with the cardiometabolic syndrome (CMS) are at increased risk for type 2 diabetes and cardiovascular disease The authors examined effects of valsartan and hydrochlorothiazide (HCTZ) combined and alone on insulin sensitivity (using homeostasis model assessment-insulin resistance [HOMA-IR]), and inflammatory/metabolic biomarkers in prediabetic hypertensive persons with CMS Eligible patients entered 16-week therapy with valsartan 320 mg/d (n=189), HCTZ 25 mg/d (n=190), or valsartan/HCTZ 320/25 mg/d (n=187) At the end point, there were no statistically significant differences in HOMA-IR among the 3 groups HCTZ significantly increased hemoglobin A(1c) and triglyceride concentrations and lowered serum potassium levels vs valsartan HCTZ also increased plasma aldosterone and C-reactive protein levels Blood pressure reduction and blood pressure control rates were highest with valsartan/HCTZ There were no differences between combination valsartan/HCTZ or monotherapies on a measure of insulin sensitivity; however, the negative metabolic effects of HCTZ (increase in triglyceride and hemoglobin A(1c) values) were absent with valsartan/HCTZ, indicating an ameliorating effect of valsartan on these measures
TL;DR: The authors' results suggest that DASH diet foods are available in low‐ and high‐SES communities, but there is a strong trend toward less food availability in low-SES areas, and eating the Dash diet, however, is more expensive in high‐ SES communities.
Abstract: The authors assessed food availability and cost of the Dietary Approaches to Stop Hypertension (DASH) dietary pattern and patients' opinion concerning diet and blood pressure by surveying grocery stores and clinic patients in low- and high-socioeconomic status (SES) areas of Boston, Massachusetts. The proportion of DASH items found in stores in low- and high-SES communities was not significantly different (46.5% compared with 75%; P=.2896). The cost of eating a DASH meal plan was significantly more expensive in high-SES communities ($40.20 compared with $30.73 per week; P=.0413). The authors' results suggest that DASH diet foods are available in low- and high-SES communities, but there is a strong trend toward less food availability in low-SES communities. Eating the DASH diet, however, is more expensive in high-SES communities. Increased information, food availability, and affordability are likely to lead to more widespread adoption of the DASH diet.
TL;DR: There is a particular need for effective 24‐hour BP control in patients with obesity, diabetes, hyperlipidemia, or the metabolic syndrome, due to the increased likelihood of nondipping status, which is a risk factor for TOD and mortality.
Abstract: Hypertension frequently coexists with obesity, diabetes, hyperlipidemia, or the metabolic syndrome; their association with cardiovascular disease is well established. The identification and management of these risk factors is an important part of the overall management of hypertensive patients. Because patients in these special populations are more predisposed to target organ damage (TOD), stringent targets for blood pressure (BP) control have been set in clinical guidelines. However, clinical trial and real-life evidence suggest that these targets are difficult to achieve. Patients with these comorbidities are more likely to require combination therapy, yet physicians are often reluctant to adjust the number and doses of medications to achieve target BP. There is a particular need for effective 24-hour BP control in these patients, due to the increased likelihood of nondipping status, which is a risk factor for TOD and mortality. Not all available antihypertensives are equally effective in controlling BP over 24 hours, and some may exacerbate underlying metabolic abnormalities.
TL;DR: Whether intensive medical therapy for atherosclerotic renovascular hypertension is improved by angioplasty plus stent placement may be answered by ongoing studies, the largest of which may be the National Institutes of Health‐funded Cardiovascular Outcomes in Renal Atherosclerosis Lesions (CORAL) trial.
Abstract: Renovascular hypertension, the most common remediable cause of elevated blood pressure, is a controversial topic, but most authorities agree on several principles. The absolute risk of renovascular hypertension for a specific patient can be estimated using only clinical information, thereby sparing many patients further expensive and potentially dangerous evaluations. Patients with a high absolute risk of renovascular hypertension should have angiography only if they are willing to undergo revascularization if warranted. A screening test (captopril renography, Doppler ultrasonography, magnetic resonance angiography, or computed tomography) is recommended for those with an intermediate absolute risk. Angioplasty should be offered to patients with fibromuscular dysplasia. Whether intensive medical therapy (including an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker) for atherosclerotic renovascular hypertension is improved by angioplasty plus stent placement may be answered by ongoing studies, the largest of which may be the National Institutes of Health-funded Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial.